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How lifetime inequality drives up cost of care for older adults and taxpayers

Experts say we could save Medicare dollars and human pain by tackling people’s challenges when they’re younger

The American Psychological Association warns that socioeconomic challenges like poverty or inadequate education earlier in life consistently and reliably predict physical and mental health challenges in later life. And that adds pressure to already-strained, taxpayer-funded programs for older adults, including Medicare and Medicaid.

The key to reducing costs in programs for older adults, which experts frequently warn may not have enough money to provide for their growing ranks, could depend on family-friendly policies that target education opportunities, nutrition, housing and other help for vulnerable folks while they’re younger.

“Inequalities in health or income don’t appear magically on someone’s 65th birthday,” said Deborah Carr, a professor of sociology at Boston University and author of “Golden Years: Social Inequality in Later Life.”

She says the end product of life events and choices, which seem to make sense at the moment, could hurt over time. For example, a person may settle for a low-wage job with few benefits, inadequate health insurance and more likelihood of work-related injuries because their family needs money now and college is expensive. That could lead to living in poor-quality housing and even shorten lifespan, said Carr, also a fellow with the Gerontological Association and editor of the Journal of Gerontology: Social Sciences.

Where one fits in America’s social-class patchwork depends on factors — some changeable, some not — like gender or race or whether one lives in an urban or rural community, said Brigham Young University associate professor and epidemiologist Evan Thacker.

A lifetime of hardships and inequities can chip away at the future, creating intergenerational challenges that require more public resources in later life — sometimes for multiple generations, he added.

Experts across the political spectrum say the cost of not dealing with health and other issues as they arise in life can snowball, then crash land on programs like Medicare — a publicly funded program designed to make sure older adults have access to at least some medical care.

In “A New Contract with the Middle Class,” Brookings Institution scholars Richard Reeves and Isabel Sawhill recently wrote that “health often takes second place to health care, even though health is influenced far more by social factors than medical ones. It is clear that what scholars labeled ‘social determinants’ of health — economic resources and opportunities, education and skills, communities and neighborhoods and housing and the built environment — deeply influence health.”

They recommend rebalancing government spending, noting the benefits of providing social support “upstream,” instead of paying more — and not just in money terms — in later life.

Research says people who have access to a steady income, nutritious food, safe housing and preventive health care earlier in life grow old in better health than people who lack those things — and they need less care at public cost later. Thacker adds clean air, occupations that don’t involve certain health hazards, a community or family that’s close-knit and willing to help to the list of resources that positively influence future health.

Growing disparity

In America, socioeconomic gaps are widening at the same time the number of older adults grows. The National Council on Aging says more than 25 million Americans 60 or older are “economically insecure. … These older adults struggle with rising housing and health care bills, inadequate nutrition, lack of access to transportation, diminished savings and job loss.”

The American Psychological Association adds that about a third of those 60 and older who have a chronic illness and low socioeconomic status cannot afford food, medicine or both. Meanwhile, poverty increases risk for decline in mental health for older adults, who are more likely to have malnutrition and health problems, according to the American Psychiatric Association.

An international study in Frontiers in Public Health found social disadvantage accumulates over the lifespan, providing later-life challenges. Experts decry a “mismatch” between that accumulation and policies and resources that could head off challenges earlier and less expensively.

“Social class affects older adults’ lives in so many ways,” said Carr. “One is simply quality. If people can’t afford good housing, if they have crooked floors or broken handrails, that causes falls. That’s the No. 1 reason for ER visits. Or crooked sidewalks. If you live in a low-income neighborhood, the sidewalks are cracked. You might not have appropriate air conditioning or heating based on the climate. We know that older adults are especially vulnerable to extreme temperatures; they hurt more in heat or cold.”

Medicare does not meet all the health care needs of of an older person. The program has multiple parts, most purchased separately, like some coverage of medications. Low-income seniors may not afford parts that provide needed care. They might go without a walker, hearing aids or dental and eye care.

“If people have access to health care earlier in life — preventive care — they will actually grow old in greater health,” said Carr. “Education is a really big thing. Education is linked with longer lifespan. So public investments in schooling helps people engage in healthier lifestyles over the long term. The fact that health is based on some biology, but also behaviors and access to care when one is younger, means that the early life investments really can pay off in the long term.”

Across generations

Generational impact happens because “our family lives are absolutely intertwined,” said Carr. “The interdependent nature of families is really important. Sometimes we forget that when we talk about policy.”

For instance, a young family receiving food assistance relies less on older relatives for help. If a child receives adequate nutrition, she might do better in school and have a brighter future that puts her in a position to thrive and even help her other family members who need it later. And older adults with enough resources won’t need financial help from their younger relatives and from public programs.

According to Carr, policies that affect one person will likely affect the older and younger generation on either side of him.

“A person’s health as they age may be influenced by their own level of education and the quality of that education they attained earlier in life. But it may also be influenced by their parents’ education, and their parents’ occupations and income, which would have had influence on the children early in life and can have lasting effects into older ages,” Thacker said. “And then people’s occupations will matter for their health in old age, because whatever they spent a lot of their time doing over the course of many decades will have created certain opportunities; it will have created certain challenges and stressors.”

Medicaid provides health coverage to very low-income people and is a major funder of long-term care, either because people don’t have the resources to pay a bill that can run into the tens of thousands of dollars a year or because they burned through their own resources and now need help.

Carr said most people care for their loved ones at home until they physically cannot do it any more.

To provide help, though, policymakers and legislators have to consider tradeoffs and priorities to figure out where money should go. That may pit long-term care that’s direly needed now against funding financial aid that could enable an education that might help someone need less taxpayer-funded services later.

It’s a dilemma, Carr, Thacker and others agree.

“The more challenges you have in life, whether exposure to poverty or systemic racism, both of those factors mean that you’re going to suffer later-life health problems at an earlier age. Someone with a really grueling job is more likely to have aches and pains at 50, rather than 70,” said Carr, who noted the value of efforts to help people get preventive care when they’re younger. “If you have those investments a bit earlier, that might kind of push out or delay the extent to which people really need to rely on very expensive medical care.”

Old age for millions of people is nothing like a pharmaceutical advertisement on TV, with healthy folks out boating, said Carr.

Having insurance improves the chance something like pre-diabetes can be spotted and lifestyle changes made before it becomes diabetes, a life-altering, expensive and potentially fatal disease, said Thacker.

Older people may also have multiple diseases at once. So the person who started out with pre-diabetes may end up with high blood pressure, heart disease and kidney disease, for example. He or she is more likely to need expensive medications and require more healthcare resources later in life. Such factors drive up Medicare costs.

Unemployment, access to health care and wages are among the issues that President-elect Joe Biden has promised to address, but the details he’ll champion or how it will play out in Congress are far from clear given the existing political temperament.

Meanwhile, experts continue to weigh in on how to help those who struggle. Influential articles in the field of public health argue that if we want to understand how to improve people’s health, we cannot focus on improving their personal health behaviors, separated from the context of their social circumstances, said Thacker. “That’s a big, big idea in sociology and public health.”

Resources that help a young person develop to full potential, from excellent education to exercise and good food, are believed to make a difference later on.

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